Provider Demographics
NPI:1376592477
Name:WILLOUGHBY, WALTER J JR (MD)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:J
Last Name:WILLOUGHBY
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5590 S FORT APACHE RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-7657
Mailing Address - Country:US
Mailing Address - Phone:702-382-4814
Mailing Address - Fax:702-598-3718
Practice Address - Street 1:10105 BANBURRY CROSS DR
Practice Address - Street 2:STE 355
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89144-6646
Practice Address - Country:US
Practice Address - Phone:702-998-1400
Practice Address - Fax:702-998-1333
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NV4004207RC0200X, 207RP1001X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1376592477Medicaid
NV1376592477Medicaid
E34533Medicare UPIN